594433
research-article2015
EMR0010.1177/1754073915594433Emotion ReviewBrion et al. Affective Processing in Korsakoff Syndrome
ARTICLE
Beyond Cognition: Understanding Affective
Impairments in Korsakoff Syndrome
Emotion Review
1­–9
© The Author(s) 2015
ISSN 1754-0739
DOI: 10.1177/1754073915594433
er.sagepub.com
Mélanie Brion
Fabien D’Hondt
Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Belgium
Donald A. Davidoff
Harvard Medical School, Harvard University, USA
Department of Neuropsychology, McLean Hospital, USA
Pierre Maurage
Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Belgium
Abstract
As earlier research on Korsakoff syndrome (KS), a frequent neurological complication of alcohol-dependence (AD), mainly focused
on cognition, affective impairments have been little investigated despite their crucial impact in AD. This article proposes new
research avenues on this topic by combining two theoretical frameworks: (a) dual-process models, positing that addictions are
due to an imbalance between underactivated reflective system and overactivated affective-automatic one; (b) continuity theory,
postulating a gradual worsening of cognitive impairments from AD to KS. We suggest that this joint perspective may renew the
current knowledge by clarifying the affective-automatic deficits in KS and their interactions with reflective impairments, but also
by offering a direct exploration of the continuity between AD and KS regarding reflective and affective-automatic abilities.
Keywords
cognition, dual-process models, emotion, Korsakoff syndrome
Introduction
Korsakoff syndrome (KS) is a neurological condition characterized by severe retrograde and anterograde memory deficits
(Butters & Brandt, 1985) and most frequently resulting from a
combination of chronic alcohol dependence (AD) and thiamine
deficiency (Oscar-Berman, 2012). Brain damages and cognitive
impairments related to KS appear far more intense and permanent than those usually reported in AD patients (e.g., Sullivan &
Pfefferbaum, 2009). Thus, this observation led to the continuity
theory (Ryback, 1971) proposing a linear worsening of cognitive and cerebral deficits between uncomplicated AD and KS,
the latter presenting much more serious behavioral and organic
impairments. In this view, KS presents an increase of the
brain and cognitive damages induced by alcohol neurotoxicity
(Oscar-Berman, 2012; Sullivan & Pfefferbaum, 2009) and
already observed in AD (Bühler & Mann, 2011). While the continuity theory has received empirical support from studies
showing a continuum between AD and KS for memory abilities
(Pitel et al., 2008), this proposal has not been experimentally
tested for the other abilities in which impairments are frequently
observed in alcohol-related disorders.
In this perspective, dual-process models (Bechara & Damasio,
2005; Mukherjee, 2010) offer an innovative theoretical background to renew the exploration of the continuity theory by
exploring its generalization towards other cognitive abilities.
Indeed, these models centrally postulate that adapted human
behaviors are based on the efficient interaction between two cerebral systems: (a) the “reflective system,” a controlled and inhibitory system involved in the cognitive processing of stimuli,
Author note: Pierre Maurage (Research Associate) is funded by the Belgian Fund for Scientific Research (F.R.S.-FNRS, Belgium). Fabien D’Hondt was funded by a “Fonds
Spéciaux de Recherche” postdoctoral grant from the Université Catholique de Louvain.
Corresponding author: Pierre Maurage, Faculté de Psychologie, Université catholique de Louvain, 10 Place C. Mercier B-1348 Louvain-la-Neuve, Belgium.
Email: [email protected]
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2 Emotion Review 
relying on memory and executive functions and initiating controlled-deliberate responses (response–consequences link), and
(b) the “affective-automatic system,” an appetitive system
involved in the impulsive processing of a stimulus and triggering
automatic responses based on associative learning (stimulus–
response link). More specifically, affective-automatic system is
considered as comprising an affective subcomponent associated
with the core affect decoding (e.g., facial expression or prosody)
and an automatic subcomponent associated with the attribution
of a pleasant or aversive value to environmental stimuli through
conditioning (Bechara, 2005; Bechara & Damasio, 2005).
Neuroscience studies (Daw, Niv, & Dayan, 2005; Hampton &
O’Doherty, 2007) have reinforced the dual-process models by
showing distinct cerebral networks underlying the two systems:
a prefrontal network (mostly orbitofrontal-dorsolateral prefrontal cortices) for the reflective system, and a limbic network
(mostly striatum and amygdala) for the affective-automatic one.
Importantly, a crucial assumption of the dual-process models is
that, in everyday life, reflective and affective-automatic systems
constantly interact in order to ensure accurate decision-making,
and therefore that their balance is the crucial factor leading to
adapted behaviors. With this in mind, these models have been
applied to addictions and particularly to AD (Wiers & Stacy,
2006), proposing that AD is characterized by an imbalance
between an overactivated affective-automatic system (leading to
overreaction to affective stimulations and to automatic approach
towards substance-related stimuli) and an underactivated reflective system (leading to a reduced ability to inhibit and regulate
these automatic behaviors). Again, the validity of these models
in AD has been reinforced by neuroimaging studies showing that
frontal (i.e., reflective system) and limbic (i.e., affective-automatic system) networks are particularly vulnerable towards
AD-related damages (Oscar-Berman & Marinković, 2007).
As underlined before, beyond the empirical support received
from episodic memory impairments (Pitel et al., 2008), the continuity theory has received very little confirmation from other
abilities, and has centrally not been tested for the processes
related to affective-automatic system and its interactions with
reflective processes. Since affective and interpersonal deficits
have been shown to play a crucial role in the development and
persistence of alcohol-related problems (Thoma, Winter, Juckel,
& Roser, 2013), a specific exploration of these processes in KS
appears important to test the generalizability of the continuity
theory, beyond the usual cognitive abilities, but also to (a) enrich
the current experimental and theoretical knowledge regarding
the impairments associated with alcohol-related disorders; and
(b) propose new therapeutic models focusing on affective and
social variables. On this basis, exploring the continuity theory in
the framework offered by dual-process models appears particularly adapted to assess the reliability of the continuity theory
towards affective processing as well as to explore affective–
cognitive interactions in KS.
This article will first provide a brief statement on the findings suggesting an overactivation of the affective-automatic
system in AD. Then, while highlighting the critical need to
explore affective processes and affective–cognitive interactions
in KS, a hypothesis will be presented (on the basis of preliminary results presented in Figure 1) suggesting abnormalities of
the affective-automatic system and systems’ imbalance in KS.
Finally, some crucial directions for future research will be proposed (Figure 2), aiming to test the continuity theory in this perspective by following three main research axes: (a) exploring
the deficits of the affective subsystem in KS; (b) exploring the
deficits of the automatic subsystem in KS, and (c) direct testing
of the interactions between the affective-automatic and reflective systems.
Abnormalities of the Affective-Automatic
System in AD
While no systematic exploration of the affective-automatic system in a dual-process model framework has yet been proposed,
several experimental results suggest that this system is abnormally activated in AD. Concerning the affective subsystem,
affective state can be globally defined as a multimodal experience (combining physiological, cognitive, and behavioral components) elicited by internal (e.g., memories, goals) or external
(e.g., perceptual stimuli) signals and which modulates future
actions and mental states (Bechara & Damasio, 2005; Johnson,
Kim, & Risse, 1985). In view of the central role played by affective states in everyday life, the effective perception and processing of affective stimuli coming from our internal or social
environment is a crucial ability to develop and maintain adapted
social interactions or, more generally, to ensure a global wellbeing. It has been shown during the last decade that AD is characterized by disturbances in a wide-range of affective functions,
and that these deficits are not only highly involved in the development of AD but also in relapse after detoxification (Thoma,
Friedmann, & Suchan, 2013). Initial affective processing studies (Kornreich et al., 2002) in AD have focused on facial expression recognition (i.e., the ability to determine which affective
state is expressed by a human face) and have revealed that AD
is associated with a global impairment in the identification of
facial expressions, and particularly with an overestimation of
the intensity of negative affects. More recent studies (Maurage,
Campanella, Philippot, Martin, & De Timary, 2008) suggested
that this deficit is specific for affective features of the face (as
AD patients are not impaired in the identification of other complex facial features such as gender or age) and is generalized to
other affective stimuli (i.e., body postures) and other sensorial
modalities (i.e., prosody; Maurage et al., 2009). It is now well
established that AD is linked with a massive modification of
affect decoding, centrally characterized by oversensitivity to
negative affective states.
Beyond this specific deficit in affect decoding, impairments
in more complex affective and social abilities have also been
recently described. Affective states decoding deficits are
strongly associated with interpersonal problems (Kornreich
et al., 2002). Similarly, it has recently been shown that AD is
linked with altered functioning in abilities combining affective
and social aspects, such as empathy (Thoma et al., 2013), and
with biased internal representations of social interactions. It
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Brion et al. Affective Processing in Korsakoff Syndrome 3
Figure 1. Schematic illustration of previous KS assessment organized according to the dual-process models perspective.
thus appears that affective and interpersonal abilities are
strongly altered in AD, and that these impairments rely on alteration of the affective subsystem. In line with this proposal, an
fMRI study (Maurage et al., 2012) has recently shown that AD
is associated with increased activation of the limbic system (i.e.,
insula, anterior cingular cortex) in a social exclusion paradigm,
indexing excessive frustration and negative feelings of the alcohol-dependent individuals when rejected by others. These data
further reinforce the hypothesis of hyper-activation of the affective subsystem when triggered by affective or social stimuli.
AD is also associated with abnormal activation of the automatic subsystem, and particularly with an excessive sensitivity
towards alcohol-related stimuli (e.g., pictures of alcoholic beverages, alcohol odors). This has been experimentally established in
a large range of paradigms, notably using attentional bias procedures. It has been shown that AD is linked with massive automatic capture of the attentional resources by alcohol-related
stimuli compared to non-alcohol-related ones (Field, Munafò, &
Franken, 2009), which, in turn, is linked with increased
physiological arousal and craving. Neuroimaging findings also
reported higher activation of limbic (i.e., insula, accumbens, cingulate) and cortical (i.e., cortex orbitofrontal and superior fontal)
brain regions for AD compared to healthy subjects during a
comparison between alcohol-related and non-alcohol-related
cues (Myrick et al., 2004). Moreover, as the intensity of this
attentional bias is correlated with increased future substanceseeking and consumption behaviors as well as with the probability of relapse after detoxification treatment, therapeutic programs
have been proposed in AD to reduce this sensitivity and thus to
potentially reduce consumption or relapse risk (Fadardi & Cox,
2009; Schoenmakers et al., 2010). These studies reinforce the
proposal made by dual-process models that alcohol acquires
powerful appetitive properties through the affective-automatic
system (Bechara & Damasio, 2005), leading to automatic
approach behaviors when confronted with alcohol-related cues.
Other tasks notably based on implicit association or memory
association (Field & Cox, 2008; Peeters et al., 2013) have largely
confirmed this overactivation of the automatic subsystem in AD
and its implication in the emergence and maintenance of drinking habits. To sum up, it clearly appears that AD is associated
with a massive overactivation of the affective-automatic system,
which plays a crucial role in the persistence of alcohol consumption. However, the functioning of this system has not been
experimentally tested in KS, which makes it difficult to draw
any conclusions concerning the modifications of this system’s
functioning during the disease evolution.
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4 Emotion Review 
Figure 2. Schematic illustration of future KS and AD assessment related to the suggested research plan following a dual-process perspective and
focusing on the affective-automatic system, the reflective system, and both systems interactions.
What is Known About the AffectiveAutomatic System in KS?
The original description of KS (Korsakoff, 1889) did not report
impaired affective and interpersonal abilities, but later studies
have repeatedly identified disturbances for these processes in
KS. These patients are indeed often described as affectively
detached, apathetic, irritable, or euphoric (Douglas & Wilkinson,
1993; Labudda, Todorovski, Markowitsch, & Brand, 2008).
These clinical observations draw attention to KS ability to process affective responses, and early findings focused on the role
played by frontal lobes in these affective changes. Indeed, frontal
lobe dysfunctions have long been identified as being involved in
KS memory deficits (Janowsky, Shimamura, Kritchevsky, &
Squire, 1989; Kopelman, 1991) as well as in executive functioning (Scott & Schoenberg, 2011). As frontal system dysfunctions
and the subsequent deterioration in executive functioning is an
important contributor to KS (van Oort & Kessels, 2009), affective changes have initially been understood as a secondary consequence of the reflective system disruption rather than as an
altered production or processing of affective stimulations per se
(Douglas & Wilkinson, 1993; Johnson et al., 1985; Snitz,
Hellinger, & Daum, 2002). For example, an exposure effect
study (Johnson et al., 1985) aiming at manipulating preferences
for a neutral melody by a mere repeated exposure suggested a
preserved ability to acquire affective response for KS as they
showed similar preferences than healthy controls. However, a
more subtle exploration of affective abilities suggested that these
functions are impaired in KS. First, the same study also showed
that, in a task involving the development of preferences towards
other individuals, KS patients were more imprecise than controls
at making a preference based on the description of the character.
Moreover, while the basic discrimination of linguistic and affective prosody appears preserved, KS is associated with serious
impairment of affective prosody perception when semantic content is neutral or incongruent (Snitz et al., 2002). This leads to the
proposal that affective abilities might be disrupted in KS when
subtle affective processing is required. One potential explanation
of these findings is that whereas basic discrimination of affective
content may be specifically associated with the affective-automatic system, complex affective processing may involve both
reflective and affective systems, leading to an altered affective
judgment due to the interaction between altered affective decoding and poor executive control (Brand & Fujiwara, 2003;
Labudda et al., 2008). This proposal is further reinforced by neuroimaging studies showing limbic and prefrontal impairments,
these areas both being involved in affective states processing
(Oscar-Berman & Marinković, 2007).
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Brion et al. Affective Processing in Korsakoff Syndrome 5
Affective recognition impairment has been extensively
explored in AD and it has been shown to strongly contribute to
nonadaptive behavior and poor social integration, which in turn
constitute major relapse factors (D’Hondt, Campanella,
Kornreich, Philippot, & Maurage, 2014; Maurage et al., 2012;
Snitz et al., 2002). Unfortunately, compared to the number of
studies of AD, there are currently very few studies assessing
affective recognition in KS, hampering the empirical testing of
the clinical proposal that KS might be associated with affective
impairments. It has nevertheless been shown that KS patients
have a facial expression recognition impairment, with stronger
difficulties for specific categories, particularly fear, anger, and
surprise (Montagne, Kessels, Wester, & de Haan, 2006). Also,
when KS patients have to categorize stimuli (e.g., words and
pictures) according to their affective valence (i.e., positive, negative, neutral), they present impaired affective judgments that
are mainly characterized by a tendency to overestimate the
affective content of neutral stimuli (Clark, Shagrin, Pencina, &
Oscar-Berman, 2007; Labudda et al., 2008). Other findings
(Davidoff et al., 1983) pointed out that KS patients had a better
memorization of short stories with sexual content rather than
neutral or aggressive ones, whereas no differences were found
among AD and healthy subjects. These findings might suggest
that motivational-affective factors (i.e., sexual content) influence KS selective attention and immediate recall in a similar
way that alcohol-related cues lead to automatic approach behaviors in AD studies (Field & Cox, 2008; Peeters et al., 2013). In
other words, this affective-motivational factor described by
Davidoff et al. (1983) which facilitates KS capacity to recall
affectively valenced stories might have been a first hint of current conceptions proposed by the dual-process models and
would correspond to the automatic subsystem.
These preliminary results offer initial indications as to how
KS patients decode affective stimuli. Nevertheless, there is no
precise detail about the nature of these impairments, especially
compared to AD patients, which reinforces the need for a thorough continuity theory investigation. Therefore, two possible
hypotheses could explain these preliminary findings: (a) in
agreement with the continuity theory, KS patients might present
an overactivation of the affective-automatic system leading to
an exaggerated perception of affective content; or (b) in case of
discrepancy in the continuity theory, KS patients would present
reduced activation of the affective-automatic system leading to
lowered arousal levels. A step beyond would be to postulate differential deficits across the subcomponents of this system (i.e.,
automatic and affective subsystems), as it might indeed be postulated that the validity of this continuity theory varies across
the automatic-affective system, a continuum being found for the
affective subcomponent but not for automatic subcomponent, or
conversely. However, the lack of data concerning the automatic
subsystem is patent, as, to the best of our knowledge, no study
has explored the deficits directly related to this subsystem in KS
and nothing is known concerning the alcohol-related attentional
and approach biases in these patients, or their implications on
craving and relapse. To sum up, whereas the cognitive alterations provoked by frontal dysfunction have been extensively
described (Oscar-Berman, 2012), the behavioral consequences
of limbic structure dysfunctions (i.e., amygdala and mammillary bodies) are far less understood. A better understanding of
these affective deficits is thus needed to determine the involvement of the automatic-affective system in KS.
What is Known About Affective–Cognitive
Interactions in AD and KS?
While the dual-process models have identified two separate systems, their main assumption is that correct decision-making
(which can be defined as the mechanism of making a choice
after analyzing possible consequences on the basis of reward
and punishment in previous experiences) relies on a constant
interaction between affective-automatic and reflective systems.
The balance between these systems is thus essential to produce
appropriate behaviors depending on the environment.
Neurocognitive studies (Mitchell, 2011) demonstrated that decision-making processes implicate constant interactions between
limbic and prefrontal networks. Interactions between affectiveautomatic and reflective systems also highly influence risky
behavior in alcoholism (Camchong, Endres, & Fein, 2014; Le
Berre et al., 2014). At first, when alcohol use is voluntary, the
reflective system (i.e., prefrontal network with orbitofrontal
cortex [OFC], dorsolateral prefrontal cortex [DLPFC], ventromedial prefrontal cortex [vmPFC)]) initiates intentional and
controlled behavior that is accompanied with reward effects
mediated by affective-automatic system (i.e., amygdala, striatum, and insula; Everitt & Robbins, 2005). Later, a transition to
compulsory consumption with less behavioral control is mediated by less activation of reflective system and more activation
of affective-automatic system (Camchong et al., 2014; Everitt &
Robbins, 2005). The imbalance between systems is thus at the
heart of addictive behaviors (Makris et al., 2008), as these
pathologies can be understood as decision-making impairments:
AD patients make choices that bring immediate reward without
considering the delayed inherent punishment (Noel et al., 2011).
Hence, they usually exhibit risky decision-making characterized by an insensitivity to future consequences, which, in turn,
contributes to dysfunctional behavior in daily life (Bechara,
2005). Even though decision-making deficits in AD are thought
to result from the interaction between impaired executive functioning and dysfunctional affective processing (Noel et al.,
2011), the direct interactions between systems have been only
minimally explored in experimental paradigms.
As the dual-process theory constitutes the dominant model
explaining AD, past studies mostly explored separately the
reflective and affective-automatic systems, leaving aside the
systems’ interaction (i.e., using a specific experimental task that
jointly examines both systems). This is even more obvious in
KS, where almost no study specifically explored these interactions. However, it has been shown that KS patients have deficits
in decision-making as conceptualized by gambling tasks such as
the Game of Dice Task (GDT; Brand, 2005). The computerized
GDT was designed to assess the impact of executive functions
on decision-making in a gambling situation in which subjects
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6 Emotion Review 
have to increase their gain by throwing dice and betting on various number combinations. In this study, KS patients were highly
impaired on GDT and these deficits were correlated with executive function impairments (i.e., categorization, monitoring,
using feedback). Interestingly though, in addition to its reliance
on the reflective system, this task is also correlated with affective processing impairments, as an efficient affective processing
of feedback from previous decisions is needed to guide later
choices (Brand et al., 2009; Oscar-Berman, 2012). In order to
disentangle the respective involvement of executive functions
and feedback-processing deficits in decision-making impairments, a modified GDT version was proposed (Brand et al.,
2009). Findings pointed out that KS patients present executive
dysfunctions, and also demonstrated that they do not take
advantage from feedback, confirming the involvement of altered
affective processing. Furthermore, in a similar gambling paradigm, the Iowa Gambling Task (IGT), a recent fMRI study (Le
Berre et al., 2014) underlined relationship between decisionmaking impairment and gray matter shrinkage in AD in cerebral
regions such as vmPFC, anterior cingulate cortex and hippocampal formation. Although not yet replicated with KS, associations between these brain regions and poor decision-making
performances in AD are another hint to better understand why
amnesic KS patients are impaired at decision-making tasks.
These initial results thus highlight the involvement of an imbalance of these systems in KS, but they have up to now not been
verified and extended using other paradigms.
Future Directions: Understanding Affective
Impairments in KS
Dual-process theories of AD have emerged during the last decade (Houben, Nederkoorn, Wiers, & Jansen, 2011; Wiers &
Stacy, 2006) and gained a dominant position in this field.
However, they have mostly been tested on recently detoxified
AD individuals, and the evolution of the deficits across the different stages of the pathology (and singularly in the transition
between AD and KS) remains largely unexplored. Centrally, the
continuity theory still has to be confirmed beyond executive
processing, through the direct comparison of the impairments
observed between AD and KS patients with respect to the affective-automatic system and its interaction with the reflective one.
The current understanding of the systems’ impairments is presented in Figure 1. While offering a valuable exploration of the
deficits related to KS, these previous studies have left many
areas unexplored, and a systematic evaluation of these dualprocess models by comparing AD and KS is needed. Given this
perspective, main avenues for future research (summarized in
Figure 2) can be proposed, relying on three research axes:
1. Exploration of the affective subsystem: Future studies
should focus on the development of a thorough exploration of this subsystem in AD and KS, first by determining the extent of this affective states decoding
deficit across complex facial features (Maurage et al.,
2008) and also examining deficits with regard to other
affective stimuli (i.e., body postures) and sensorial
modalities (i.e., prosody; Maurage et al., 2009).
Besides, visual deficits might also be regarded as a
determining factor in affective alteration, as recent
findings suggest, by mean of electrophysiological data,
that a mutual effect between affect and vision is already
seen in early stages of information processing (D’Hondt,
Lepore, & Maurage, 2014). It will also be important to
precisely identify the evolution of these deficits during
the transition from AD to KS. On this basis, more complex affective abilities and social cognition should be
explored. For instance, social interactions and the regulation of social exclusion should be assessed by reliable
tasks, for example the Cyberball Task that elicits social
exclusion feelings (Maurage et al., 2012). More ecological tasks (e.g., Interpersonal Perception Task; Mah,
Arnold, & Grafman, 2004) might also be used to evaluate fine social abilities that are essential to independently managing everyday life.
2. Exploration of the automatic subsystem: This exploration is usually conducted with two classes of tests (Wiers
& Stacy, 2006). The first class includes attentional bias
measures (ABM), essentially the Visual Probe Task
(Schoenmakers et al., 2010), a reaction-time task in
which two stimuli (i.e., one alcohol-related and one neutral picture) are presented as cues indicating the following appearance of an arrow that has to be processed. This
task is applied to determine the subject’s automatic
attentional engagement toward alcohol-related stimuli
and to measure the ability to disengage attention from it
(Schoenmakers et al., 2010). The second class includes
approach bias tests such as the Implicit Association Test
(IAT; Thush et al., 2008) in which stimuli are classified
into categories (e.g., alcohol-related or neutral) and
affective attributes (e.g., positive and negative). This test
is thought to illustrate the spontaneous association to a
cue (alcohol-related or not; Wiers & Stacy, 2006).
Although ABM and IAT may partially involve controlled
cognitive processes (Wallaert, Ward, & Mann, 2010),
these tasks are now widely used to explore attentional
bias toward alcohol-related stimuli among AD and
appear to be reliable measures of the automatic subsystem. Applying these tests to the KS population and comparing them with AD performances would directly test
the continuity theory. Indeed, it might be hypothesized
that the automatic subsystem will be even more overactivated in KS, thus confirming the continuity theory and
extending it towards the affective-automatic system. But
it might alternatively be postulated that the extension of
brain impairments related to KS will lead to reduced
activity in limbic areas and thus to reduced overactivation of this subsystem.
3. Interactions between affective-automatic and reflective
systems: Several tasks have been developed to directly
evaluate these interactions and can be applied to AD
and KS in order to directly test the main proposal of
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Brion et al. Affective Processing in Korsakoff Syndrome 7
dual-process models, that is, the hypothesis that addictions are due to an imbalance between these systems. For
example, the Emotional Stroop Task (Williams, Mathews,
& MacLeod, 1996) involves presentation of neutral and
affective stimuli (i.e., word or image) for which the subject has to maintain his/her attention on the stimulus color
rather than on the word’s meaning. A second paradigm
of interest is the Emotional Flanker Task (Barratt &
Bundesen, 2012) requiring the categorization of a
presented target face (i.e., positive or negative) while
ignoring distractor faces presented on the target’s right
and left flanks. The third task proposed to investigate the
interaction between reflective and affective-automatic
systems is the Emotional N-Back Task (Tavitian et al.,
2014) which consists in presenting a sequence of letters
flanked by affectively laden faces (i.e. happy, fearful,
neutral) and asking the subject to respond to a letter that
matches another one presented N steps earlier.
In conclusion, by means of a solid theoretical background
such as the dual-process system model, this article underlines
the usefulness of simultaneously exploring affective processing and clarifying the relationship between affect and cognition
among AD and KS patients. At the clinical level, adding an
examination of KS automatic/affective processes could facilitate KS care in psychiatry and neurology. A clinical perspective
could make use of attentional bias modification training
(Schoenmakers et al., 2010), which is a modified visual probe
task in which a probe replaces neutral stimuli in all trials.
Concretely, the subject is trained to disengage attention from
alcohol-related cues (Schoenmakers et al., 2010). Moreover, a
better understanding of KS affective processing could promote
the development of new rehabilitation tools to reduce interpersonal difficulties encountered by KS patients. At the fundamental level, comparing AD and KS performances with the
aforementioned tasks could help to step forward to the investigation of the classical continuity theory, as there is, to date, no
proposal concerning the evolution of affective-automatic disturbances from AD to KS. It might indeed be hypothesized
that: (a) as assumed by the continuity theory, KS would show
an overactivation of the automatic/affective system or (b) on
the contrary, a reduced activation of the automatic/affective
system would be observed among KS. Also, this hypothesis
may vary across the system itself, a continuum being found for
the affective subcomponent but not for automatic subcomponent, or vice versa. It should also be noted that several factors
related to demographical (gender, age, family history of alcohol consumption) and psychopathological (personality traits,
comorbid depression or anxiety, dual diagnoses) variables
should be taken into account and controlled for in future studies, as they might constitute risk factors strongly influencing
the results observed (Finn, Sharkansky, Brandt, & Turcotte,
2000; Schuckit, 1994). Moreover, while the present article
focused on alcohol-related KS, it should be underlined that KS
can have non-alcohol-related etiologies (e.g., be provoked by
strictly nutritional deficiencies; Larnaout et al., 2001; Peters,
Parvin, Petersen, Faircloth, & Levine, 2007), the continuity
theory of course being inapplicable to such cases.
Besides, future research should likely incorporate neurophysiological correlates involved in reflective–affective processes and their interactions. A fundamental perspective could
be the exploration of “the triadic neurocognitive approach to
addiction” proposed by Noel, Brevers, and Bechara (2013)
which includes a third axis (i.e., the insular system) considered
as a modulator of the interactions between reflective and affective-automatic systems. To this end, the triadic model (Noel
et al., 2013) would be an important consideration if placed in
the context of continuity theory (i.e., comparing AD and KS
neural correlates of these three systems).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
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